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Tuesday, May 19, 2009

Abortion and medical ethics

An anonymous commenter* points out that Obama, when he said, "Let's honor the conscience of those who disagree with abortion, and draft a sensible conscience clause," probably meant allowing health-care workers to exercise their personal consciences and deny abortion services to patients. This is a very dangerous precedent.

It is an important canon of medical ethics that all medical practitioners act unconditionally in the best interests of the patient, and suspend their own personal, moral judgment of their patient's character. We trust all medical practitioners with our very lives, and surrender an incredible amount of dignity to them (ever had a colonoscopy?) If we cannot trust them to act in our own best interests, the medical field collapses. (Well, collapses more than it already has in our capitalist economy, where it's easier for a rich person to get liposuction than a poor person to get treatment for a heart attack or stroke.)

With the increasing centralization of medical services, most people — especially poor people, and most especially poor women — don't have a choice: You go to the big general hospital in your city, or you do without, even if you have to lie down and die.

We would justly object if someone demanded we "honor their conscience" and allow them to refuse treatment to black people, or gay people, or Jews or Christians or atheists... or smokers or fat people, or motorcycle riders. Why should we object one bit less if someone demands we honor their conscience and allow them to refuse treatment — any medical treatment — to women?

If Catholic hospitals want to prohibit abortions, let them give up their non-profit status, and pay corporate income and property taxes just like any other any other capitalist business that wants to make more-or-less arbitrary distinctions in its services. If individual medical personnel working at tax-exempt or government-run hospitals don't want to perform or participate in abortions, they can move to a different specialty or different occupation. There are many fields other than medicine a person can go into, and many specialties within medicine where abortion is simply irrelevant; I recommend proctology.

But just like the opposition to Roe v. Wade is really targeted at Griswold v. Connecticut, the "conscience" issue is not really about abortion, it's about contraception, and it's about people — let's be frank, fundamentalist Christians — using their professional privilege to dictate the moral behavior of others.

Obama is no more a friend of women than he is a friend of progressives, liberals, the working (and soon-to-be unemployed) masses of Americans, or international humanity. He knows he has to kowtow to the Christian fascists to to maintain his personal power, and women are the easiest victims to sacrifice. But the fascists will not be happy with just the sacrifice of women; in just the same sense Czechoslovakia gave Hitler a hunger for more.

21 comments:

I appreciate your points. However, I am not convinced it is fair to say that abortion and contraception are "medical treatment."

Not having access to these things does not endanger anyone's life. In fact, they have the explicit purpose of interfering with normal bodily functions.

Thus, abortion and contraception are really more comparable to cosmetic surgery. No one has to have them in order to remain healthy and alive. That is why private health insurance typically does not cover purely cosmetic procedures, and plastic surgeons routinely decline to operate on people whom they judge might be harmed by the procedure.

You seem to be confused. Health providers are not objecting to their obligation to treat patients without bias; they are objecting to the nature of the procedure because it violates the harm principle.

It's possible for good doctors to disagree on the best course of treatment for a given patient. With the case of abortion, the disagreement revolves around the recognition of many providers that biological life begins at conception.

The only particularly religious inference regarding abortion is that killing human beings is wrong. If this is an unwarranted imposition of religious beliefs, you have much bigger fish to fry than conscience clauses and pro-life doctors.

Not having access to [abortion or contraception] does not endanger anyone's life. -

With all due respect, Patrick, you have no fucking idea what you're talking about.

First, medical treatment is not simply concerned with preserving life, but also preserving and enhancing health and well-being. Under your formulation, treatment for a broken leg would qualify as (elective) "cosmetic surgery", since you probably won't actually die of an untreated broken leg.

Despite impressive gains in safety in recent decades, pregnancy remains risky business. From early in pregnancy until some weeks after its conclusion, pregnant women are at increased risk of morbidity and mortality compared with women who are not pregnant. This review summarizes recent national data from the U.S. Centers for Disease Control and Prevention, including vital statistics from the National Center for Health Statistics. Ectopic pregnancy is substantially more dangerous (38 deaths/100,000 events) than either childbirth (nine) or legal abortion (less than one). The three leading causes of maternal death today are pregnancy-induced hypertension, hemorrhage, and pulmonary embolism. Although comprehensive data on pregnancy-related morbidity are lacking, about 22% of all pregnant women are hospitalized before delivery because of complications. Women of minority races have much higher risks of death than do white women, and the same holds true for older women and those with limited education. For most women, fertility regulation by contraception, sterilization, or legal abortion is substantially safer than childbirth.Get your facts straight, and get them straight before you open your mouth. This is your first, last and only warning; the next time you spout obvious falsehoods contradicted by six seconds using Google, I will not be the model of grandfatherly kindness I am right now.

Why are you upset that someone who believes that abortion is murder might be allowed to not perform abortions?

A prolife obstetrician that left the United Kingdom to escape being forced to perform abortions remarked that an obstetrician's patients always come in sets of at least two, and any treatment of the mother must account for how it affects the unborn.

If men should not have a say in the abortion debate because they cannot become pregnant, woman should not have a say because they are already born.The Catholic Church does allow women to be treated for ectopic pregnancies. It is sad that the treatment kills the child, but that is a secondary effect of treating the woman, not the primary effect. In fact any treatment to save a woman's life is licit, even if it has the secondary effect of killing an unborn child.

I have seldom if ever encountered a pro-lifer who actually gives a shit if other people contracept. Moreover, abortion is not invariably a religious issue; there's no reason why an atheist or an agnostic shouldn't believe that one person's humanity is not revocable at the whim of another.

If individual medical personnel working at tax-exempt or government-run hospitals don't want to perform or participate in abortions, they can move to a different specialty or different occupation.Perhaps a solution would be to make abortion a separate specialty within medicine. Those who are willing to practice it, can do so without interference, while those who aren't are no more required to than an abortionist is required to practice ophthalmology.

True, pregnancy is not entirely risk free. Surely you will agree that pregnancy is (other than cases of rape) the result of a woman's voluntary decision to engage in the act that causes it.

What is really at stake here, then, is the ability of people to engage in sexual behavior without having to accept the well-known consequences.

Are you seriously arguing that a "sensible conscience clause" will keep anyone who wants an abortion or contraception from getting it? Is it really that hard to find a willing provider? Apparently not, since so many folks use these services already. So why force people who would rather stay out of it to be involved?

I have not read your blog extensively, but you appear to be someone who believes in personal responsibility and accountability for one's own actions. So I think you're being inconsistent here. Maybe I'm wrong. If you can explain without raising your blood pressure, please do so.

they are objecting to the nature of the procedure because it violates the harm principle.If it does indeed violate the principle "do no harm", then abortion should be universally prohibited.

It's possible for good doctors to disagree on the best course of treatment for a given patient.Best only in the sense of most efficacious to achieve the well-being of the patient in the patient's own terms. Physicians and medical personnel don't get to determine what the patient wants.

The only particularly religious inference regarding abortion is that killing human beings is wrong.That's egregiously false, even according to the religious. The religious inference is whether blastocysts and fetuses are persons, with not only an unconditional right to life, but also a legitimate and unconditional claim on the mother's body and health.

And very few people believe killing even actual sapient persons (much less the vague and tendentiously-defined "human beings") is unconditionally wrong: we condone killing in self-defense and in war, we kill brain-dead human beings for their organs, we allow terminally-ill people to die.

And, of course, there is the obvious, historically-rooted and pervasive misogyny of all the Abrahamic religions, which most definitely influences the debate.

Such reductive misstatement of the moral issues around abortion goes beyond simple error into mendacious fucktardery.

Liam, Richard, Patrick: You have had your say here, uncensored and unedited. Now go fuck off and go play with your fellow knuckle-dragging, invisible-sky-fairy-worshiping, ceiling-praising, wife-beating, slut-raping troglodytes.

It is a good point about doctor's having differences of opinion about the best treatment. The final decision is the patient's but it might involve changing doctors. If a patient wants surgury and his doctor does not agree that it is the best treatment then he can find another doctor who agrees with him. Forcing his original doctor to do the surgury is both immoral and stupid. Immoral because no doctor should be forced to do a surgury he does not feel is in the best interests of the patient. Stupid because people tend to mess up when doing something they don't believe in. You want your doctor onside 100%.

So why is abortion any different? If a doctor thinks it is a bad idea then you find another doctor. Does it really matter why he feels it is a bad idea? It is still immoral and it is still stupid.

A state with legalized death penalties decides the person to be executed should have a doctor available to do the killing, to ensure that the killing is as painless and humane as can be. This isn't a far-fetched hypothetical, see this articleMany reasonable doctors will object to killing people. Should they be allowed to opt out of doing such legal medical interventions? Should there be a conscience clause for these doctors?

I don't think any physician should ever assist in executing anyone: an execution is not, I'm confident, in the best interest of the patient.

The point is that a physician should never raise her personal conscience or moral beliefs over the best interests of the patient. If a physician has strong moral feelings about issue, feelings that would make it difficult for her to act in the best interests of the patient, she should go into a specialty where that issue will never come up.

I swear by Apollo the physician, by Æsculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgement, the following Oath.

"To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

Your insistence that health care workers get jobs in areas of health care not likely to encroach on their moral consciences, rather than insist on the right to refuse to perform or participate in procedures based on personal morals, is already being taken to heart. It's long been the case that the reduction in the number of abortions in the U. S., as well as the lack of access to abortions for so many women, has less to do with laws restricting abortion rights and more to do with the difficulty of abortion clinics to find doctors and nurses willing to perform abortions. This is partly, no doubt, because of pressures placed on clinics and their staff by pro-life activists. But, more than that, it is because more and more doctors and nurses have moral reservations about abortion. This is why many medical schools, under pressure from abortion rights activists, started requiring that students learn how to perform abortions, because so few were voluntarily learning to do so. If conscience rights are rescinded, even more doctors and nurses will take your advice and move to fields where abortion is not an issue, and the dirth of health care workers in the field of obstetrics will only get worse.

But it will hardly end there. Obstetrics is not the only field where health care workers face moral dilemmas: neonatology, critical care, psychology, oncology, hospice, etc... Even, to a certain extent, med/surg. I don't think any of my colleagues at my hospital would deny any patient care that is in their best interest. But that is the crux: what, exactly, is in the best interest of the patient. It isn't always black and white, and I doubt that any doctor or nurse would agree that the best interest of the patient means providing care "most efficacious to achieve the well-being of the patient in the patient's own terms." There are simply too many variables to make such a vague policy practical or meaningful in any way and, yes, how far the doctor or nurse is willing to go, or what they are willing to do is one of those variables. Troublesome and/or horrific consequences of such a policy are legion.

No health care worker in his or her right mind is going to adopt a personal standard of practice that requires them to leave their conscience outside the hospital door. No health care worker regards him or herself as nothing more than a tool of the state, doing the bidding of the state, or any particular patient, no questions asked and, if you don't like it, be a plumber. You think the shortage of nurses is serious now? Do you care at all about having health care that even approaches professional standards when you need to go to the ER for that broken arm that won't kill you (though, in fact, it might)?

It has long been my practice to offer additional prominence to thoughtful, substantive and well-reasoned opinions that differ from my own, by publishing those opinions -- with, of course, proper attribution, as blog posts and not just comments.

With your permission, I'd like to post your comment as a post, where it will be seen by all my readers, not just those following the comments of this post.

I have some other thoughts to offer in response to some of what you said in your responses to others. Because I work on weekends and my time is limited, however, I'll have to wait until Monday to post them.

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